NURS-FPX6610: Introduction to Care Coordination

Comprehensive Needs Assessment

Learner’s Name

Capella University

NURS-FPX6610: Introduction to Care Coordination

Instructor Name

August 1, 2019

Comprehensive Needs Assessment

A comprehensive health needs assessment of patients enables health care providers to

systematically use their resources to disperse care efficiently. In this paper, a comprehensive

needs assessment of a simulated patient is discussed to highlight the importance of

comprehensive needs assessments in identifying and reducing gaps in patient care and

implementing effective care coordination. This paper discusses the various dimensions of a

patient’s needs and the strategies to extract relevant patient information to understand these

needs to establish the significance of a health needs assessment. This paper also presents

effective evidence-based practices in care coordination and the importance of a multidisciplinary

approach to patient care for improving health care outcomes.

Current Gaps in Mr. Decker’s Care

Mr. Decker is a 79-year-old diabetic patient readmitted to one of Vila Health’s hospitals.

Initially admitted with a badly infected toe, Mr. Decker’s inability to adhere to medical

instructions after discharge has resulted in him being readmitted with sepsis. Mr. Decker’s

readmission can be attributed to the following gaps in care:

• Lack of an interdisciplinary approach to care: The inability of the health care provider to

ensure that factors such as diabetes and aging are given due consideration while dispersing

care

• Failure to ensure adequate post-discharge support: Lack of adequate efforts from the care

provider to ensure that the patient effectively carries out the post-discharge care instructions

• Lack of consideration for the patient’s financial standing: The patient’s poor financial

standing was not considered during the design and management of the patient’s care

To ensure that Mr. Decker’s physiological, social, religious, and psychological needs are

effectively addressed, the needs assessment tool adopted is the Patient Centered Assessment

Method. The method is an integrated needs assessment tool that assesses patients’ physical,

social, psychological, and mental well-being needs. The tool was selected because it is action

oriented. It facilitates the addressal of patients’ holistic needs, expanding beyond the realm of

physiological health care to address their psychosocial needs (Maxwell et al., 2018).

Informational Needs for Patient’s Optimal Care:

An effective assessment of Mr. Decker’s current care needs depends on the following

types of information:

• Mr. Decker’s clinical information, namely age, allergies, weight, current diagnosis, and

medical history (Kelley et al., 2013)

• Personal information such as his schedules, preferences, typical behaviors, and interests,

which will provide clarity on how Mr. Decker’s care needs are to be addressed (Kelley et al.,

2013)

Strategy for Gathering Additional Necessary Assessment Data

As a personal interview does not help gather all the information necessary for the

adequate delivery of care, the following data collection strategies are formulated:

• Thoroughly scanning Mr. Decker’s activities across social media platforms to collect

information about his behavior patterns, his daily routines, and the significant events he has

been a part of will help provide clarity on his personalized needs and the various interrelated

factors affecting his care.

• In-depth interviews with close relatives and friends about Mr. Decker’s habits, nature, and

recent activities will help understand the factors that affect care and facilitate personalized

• The electronic health record systems at Mr. Decker’s preceding health care providers are

important sources of clinical information. Health information exchange systems are set up to

access Mr. Decker’s longitudinal clinical data from different health care providers to get

clarity on the various factors such as diabetes and aging that have a bearing on his current

condition. The clinical history will help ensure that Mr. Decker’s care addresses these

interrelated factors and facilitates a holistic treatment.

Societal, Economic, and Interdisciplinary Factors Affecting Patient Care

The factors affecting Mr. Decker’s health care outcomes are the following:

• Aging: The physiological changes that occur in an aging person present immense challenges

in the diagnosis, treatment, and recovery of geriatric patients (above 60 years of age) with

sepsis. Geriatric patients usually show atypical, non-specific symptoms such as altered

mental status, lethargy, dehydration, loss of appetite, and weakness, making the diagnosis

challenging. Being an inflammatory consequence to an infection, sepsis is conventionally

diagnosed using systemic inflammatory response syndrome criteria, which are not normally

met by geriatric patients. According to Clifford et al. (2016), geriatric patients undergo

pharmacokinetic changes, namely degeneration in the ability to absorb, metabolize,

distribute, and eliminate drugs. These pharmacokinetic changes have significant implications

on the treatment of sepsis and, consequently, result in the need for special considerations

while treating geriatric patients. Also, geriatric adults usually witness immunosenescence

(changes in the immune system), which impedes the swiftness of the recovery process

in geriatric patients (Clifford et al., 2016).

• Financing for health care: Mr. Decker is a 79-year-old man whose accessibility to health care

depends primarily on Medicare, the national insurance health care program. Although

Medicare covers hospitalization and medical insurance, the level of care depends on the type

of insurance plan opted. The 2019 cost estimates for Medicare stand at 437 U.S. dollars as

the premium per month for the hospital insurance plan (Part A) and 135.50 U.S. dollars as

the premium per month for the medical insurance plan (Part B), with higher costs for other

high-end plans (U.S. Centers for Medicare and Medicaid Services, n.d.). Mr. Decker’s dismal

income status has affected the nature of the Medicare plan he could afford, thus impacting

care outcomes.

• Social support: Mr. Decker has limited social support in the form of an aged wife who lives

with him, a daughter who visits them occasionally, and his nephew and nephew’s wife, who

offer occasional assistance. This limited social support has had a significant bearing on his

ability to carry out the care instructions laid out by the care providers. Many studies provide

evidence about the impact of social support on health outcomes. In a study by Schöllgen et

al. (2011), the participants interviewed reported that increased social support was associated

with functional and subjective improvements in health (as cited in Rapoza et al., 2016). A

study conducted by White et al. (2009) found that geriatric adults with insufficient social

support reported poorer health outcomes than geriatric adults who were satisfied with their

present social support (as cited in Rapoza et al., 2016). The inadequacy of social support in

Mr. Decker’s case has been the basis for the worsening of his health condition from a simple

toe wound to sepsis.

• Diabetes: The fact that Mr. Decker is also diabetic has impacted his care by making him

vulnerable to contracting infections at a higher rate and facing increased chances of

prolonged mortality as a result of sepsis. This can be substantiated by the fact that diabetes

causes a decline in the functioning of a patient’s immune cells, diminishing the ability to

clear bacterial formations and increasing infection complications (Frydrych et al., 2017).

Relating Patient Care and Care Coordination Outcomes to Professional Standards

The outcomes of patient care and care coordination can be accounted for by measuring

the patient safety and quality outcomes of patient care and care coordination. Patient safety

outcomes for specific patient care coordination are measured against the standards laid out in the

National Quality Forum’s safety report for 2017 and The Joint Commission’s National Patient

Safety Goals for 2019. The rationale for measuring safety outcomes based on the National

Quality Forum’s safety report is the comprehensiveness of the report and the credibility of the

forum, whose primary focus is the development of safety measures (National Quality Forum,

n.d.). The rationale for selecting The Joint Commission’s National Patient Safety Goals as a

standard for patient safety is that the goals are developed based on the suggestions of a highly

interdisciplinary advisory group and the analysis of national sentinel event data (Armstrong,

2014). The quality outcomes of care coordination will be measured using the Care Coordination

and Transition Management Logic Model for registered nurses as the standard (Haas & Swan,

2014a). The rationale is that the logic model not only lays out care coordination quality outcomes

but also offers holistic linkages between nurse competencies, care coordination, and outcomes

(Haas & Swan, 2014b). Also, the logic model offers an innovative approach for interprofessional

teams focusing on patient-centered care (Haas & Swan, 2014a).

The Joint Commission annually releases patient safety goals, which have been deemed

nationally as qualitative standards for patient safety. Some significant standards for patient safety

are identification of a patient by both name and date of birth, dispersal of the right test results to

the right patient, accurate labeling of medicines, medical device alarms going off in real time,

and ensuring infection prevention, which will set the right benchmark for ensuring effective

patient safety outcomes (The Joint Commission, 2019). In terms of The Joint Commission’s

standards for patient safety, the care to Mr. Decker was characterized by 100% infection

prevention during acute care, accurate administration of medicines with no adverse effect on the

body, and a successful operation without any complication. Some important care coordination

quality outcomes defined by the Care Coordination and Transition Management Logic Model are

the needs assessment’s taking into account patient needs, preferences, and goals; transmission of

the patient’s care plan with zero errors; constant updating of care coordination plans; evidence-

based practices’ achieving treatment outcomes of 80%; and optimal understanding of the

interdisciplinary roles between team members (Haas & Swan, 2014b). On this front, the specific

patient care coordination witnessed 70% treatment outcomes, the patient’s care plan was able to

accommodate 90% of the patient’s needs and preferences, and the care plan was updated in a

timely manner with zero issues reported within the cross disciplinary team.

Evidence-Based Practices for Successful Implementation of Patient Care Coordination

The following evidence-based practices have been identified to be effective in

implementing successful care coordination for patients with sepsis:

• GENeralized Early Sepsis Intervention Strategies (GENESIS) is an initiative launched for

the continuous improvement of the quality of care for patients with sepsis. GENESIS is a

comprehensive program with highly pertinent treatment measures such as implementing

institutional assessments for the prevalence of sepsis and mortality, identifying sepsis emergencies,

executing 6-hour sepsis bundle interventions via highly coordinated sepsis teams, and implementing

feedback. In their study on the impact of GENESIS on a treatment group of 4,801 patients, Cannon

et al. (2012) found an average in-hospital mortality reduction of 14% and a reduction in the duration

of stay of 5.1 days in comparison to patient groups that did not receive treatment under GENESIS

(as cited in Perez, 2015).

• Another effective practice can be the adoption of a centrally coordinated, multifaceted

quality improvement program implemented by many hospitals in Brazil (Noritomi et al.,

2014). Noritomi et al. (2014), in their study of 10 private hospitals implementing the

program, found the initiative to include two phases. The first phase comprised establishing a

local committee, setting up a screening procedure for the early detection of sepsis, carrying

out proven treatments, establishing guidelines for empirical-based antimicrobial therapy,

formulating specific routines for swift laboratory sampling, and establishing routines to

enable the efficient administration of antibiotics. The second phase included the collection

of data and creation of reports on the rate of compliance and mortality in line with the

benchmarks set by the hospital. This practice is a promising one to adopt as Noritomi et al.

(2014) found that the studied hospitals showed a decrease in mortality rates from 55%

before the implementation of program to 26% after the implementation of the program.

Best Practices from the Perspective of Population Health on Patient Outcomes

From the population standpoint of improving the health outcomes of geriatric patients

with sepsis, the following care practices are found to be credible and effective:

• As geriatric patients show atypical, nonspecific symptoms (Clifford et al., 2016), a study by

Singer et al. (2016) found the sequential organ failure assessment score a valuable tool in

determining signs of organ disfunction and mortality and, thus, helpful in the diagnosis of

sepsis. Singer et al. (2016) found that the sequential organ failure assessment score has

widespread familiarity in the clinical care community and serves as an acceptable marker for

mortality risks.

• The Surviving Sepsis Campaign guidelines, which are widely accepted, formulate the Sepsis

Six bundle as a best practice for the treatment of sepsis (Lat et al., 2018). Hancock (2015)

describes the Sepsis Six bundle as an early intervention program that calls for each patient to

receive three diagnostic and three therapeutic steps to treatment within the hour of

recognition of the health condition (as cited in Lat et al., 2018).

Benefits of Multidisciplinary Approach to Patient Care

Mr. Decker is an old patient with multiple diagnoses and several complex and multiple

needs. A multidisciplinary approach to health care through effective consultation and

collaboration involving Mr. Decker, family support, and interdisciplinary teams serves as the

only approach that can address the complex multimorbidity, social issues, and psychological

issues faced by him (Department of Health & Human Services, n.d.). This multidisciplinary

approach to patient care can also reduce the gaps due to societal, economic, and interprofessional

factors. The approach is built on egalitarian-based collaboration between interdisciplinary teams

that helps break the hierarchy existing in traditional health care organizations and, thus, improves

the satisfaction of employees in the workplace (Hughes, 2018).

The adoption of a multidisciplinary approach to patient care ensures improved patient

outcomes. In their study on improving operating room efficiency, Oyderk et al. (1988) found

that the adoption of multidisciplinary operating room teams improved turnover time by 16

minutes and considerably decreased delays when compared with operating room teams that are

not multidisciplinary, resulting in reduced hospitalization costs (as cited in Epstein, 2014). This

study supports the argument that a multidisciplinary approach to patient care helps reduce the

duration of stay, reduce hospitalization costs, and improve patient satisfaction.

Conclusion

A comprehensive needs assessment of patient care is presented in this paper through the

case of Mr. Decker. This paper successfully identifies the various interrelated factors, such as

aging, diabetes, social support, and financial conditions, that need to be addressed for a patient to

achieve optimal care. The studies presented in the paper have identified credible standards for

the specific care coordination outcomes to draw measures from. This paper successfully

identifies holistic and judicious evidence-based practices for managing sepsis. Finally, a strong

case for a multidisciplinary approach to care coordination is presented with empirical evidence.

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Comprehensive Needs Assessment
Learner’s Name
Capella University
NURS-FPX6610: Introduction to Care Coordination
Instructor Name
August 1, 2019
Current Gaps in Mr. Decker’s Care
Informational Needs for Patient’s Optimal Care:
Strategy for Gathering Additional Necessary Assessment Data
Societal, Economic, and Interdisciplinary Factors Affecting Patient Care
Relating Patient Care and Care Coordination Outcomes to Professional Standards
Evidence-Based Practices for Successful Implementation of Patient Care Coordination
Best Practices from the Perspective of Population Health on Patient Outcomes
Benefits of Multidisciplinary Approach to Patient Care
Conclusion

NURS-FPX6610: Introduction to Care Coordination

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